- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $2,137.96 / $6,456.54
| Facility | | $512.86 | $2,137.96 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $457.09 / $1,096.48
| Professional | | $295.12 | $457.09 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $1,202.26 / $4,897.79
| Professional | | $309.03 | $1,202.26 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $501.19 / $1,000.00
| Professional | | $346.74 | $501.19 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $758.58 / $1,148.15
| Professional | | $524.81 | $758.58 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $549.54 / $4,168.69
| Facility | | $213.80 | $549.54 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $478.63 / $977.24
| Professional | | $316.23 | $478.63 | $977.24 |